This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Tuesday, 28 April 2009

Don't be afraid of me!

I have been having some random thoughts and since I use this as a diary type thing I thought I would post it. There is a pile of ironing I really don't want to tackle right now.

I know that I post a lot about angry ranting screaming relatives who have unrealistic expectations. Their view of nursing and what the nurses are able to do is very far away from reality. They can get very aggressive and nasty. They have not yet realised that the situation on acute medical wards (which is where elderly patients go nowadays, to get mixed in with acutely ill patients) is one of triage rather than holistic care. The nurses do not have a choice or any control as to how long they spend with the patients on most shifts. These angry screaming people bother me a lot, even though I should just learn to shrug it off.

I do not, however, have a problem with complaints and questions. No half decent nurse would. As long as you can do it without calling me a fucking lazy bitch and implying that I hate old people it's all okay. I want to hear your concerns, questions, etc. It helps me care for you better.

It always seems to be a case of extremes rather than a gray area.

For every single ranting and raving lunatic we have 10 people who are scared shitless of the nurses, doctors and hospitals in general. I have come across many patients and relatives who are bloody terrified of "upsetting" or "offending" or "questioning" the nurse etc. There is no need to feel that way. We get yelled at a lot and get called some pretty foul names by people. I can put that aside and give them the best nursing care that I am capable of giving. We are trained to do that. If I can handle that I can easily handle hearing your questions, concerns and complaints. sometimes really nice, reasonable people lose it and flip out and we understand that. It won't get held against you.

When I see patients afraid to speak out it really saddens me. I always try and make my patients feel like I am approachable. I think the nurses that I work this also try and make themselves approachable.

One day I saw one of the patients looking really worried. I asked Mrs. P. what the problem was and she said "nothing" in a way that told me that something was really wrong. So I asked her again.

Finally she told me that she did not understand why she was given a certain new tablet rather than her old ones. She said that she was afraid to ask because she did not want to appear to be questioning the nurses or complaining. I totally reassured that we are happy for her to ask and that we think it is better if she understands her plan of treatment. I explained why the tablet she was on at home was stopped by the doctors and the new one commenced.

We should be explaining each and every drug to the patient anyway during the drug round anyway but the fact is we are too rushed.

There are lots of patients like Mrs. P. They are so afraid of "rocking the boat" or upsetting someone that they stay silent. They are afraid that we will be cruel intentionally if they "offend" us by asking a question or complaining. This is so sad.

The nurses and the doctors are on your side. I know we seem rushed and everything else but seriously we are there to do our best for you whether you are nice or nasty, bright or not so bright, pleasant or abusive etc.

Not that long ago I had a relative approach me because he was concerned about some aspect of his mother's care. The information he gave me really helped me to understand the patient better and I was duly grateful to him for saying something. He mentioned that he was afraid to "complain" because he didn't want the nurses to take anything out on mother.

In my 13 years of nursing I have never seen a nurse take a complaint out on a patient. I have seen people who have praised the hospital repeatedly to the press and people who have complained violently both get neglected because there was someone sicker on the ward. But I have never seen a nurse intentionally treat someone like crap. Have the places I worked been so unique?

This kind of abuse must happen though. You hear people mention it all the time. I know that there are wards out there with negative vibes and a bullying culture. But is it really so widespread?

I can't imagine sitting in handover and hearing someone say "Mr. R's daughter wrote a letter complaining about the nursing care, let's get him!" The worst we would ever say is "they don't understand" or "oh crap, we missed the boat". Then we will walk on eggshells around them. I have made stupid mistakes and I have admitted them and apologised. Honesty goes a long way with most people. Being brutally honest, showing remorse, and sincerely apologising goes a long way to avoiding an official complaint. I once made a communication errorto a relative and had no one to blame but myself. I wasn't even busy.

If any nurse on my ward was running around being mean to all the patients the rest of us would have her for lunch. Instantly. We would be in the managers office tattling on the nasty nurse like a bunch of high school girls. You can't work with someone like that. We do not do bullying on my ward. If a member of staffed is deemed dangerous and rude then we deal with it. We nip it in the bud. It happened once with a new HCA who talked down to patients. We spoke to her and things didn't improve and we got rid of her. If a patient is getting really nasty we are firm but professional and he still gets his care. We do support each other if one of us is struggling. We also compete with each other in a friendly way.

We have egos the size of Texas, but we also have integrity. We all want to be supernurse with all the thank you cards. We often fail, and get a lot of complaints. But we keep going. We are way too professional to go around bullying people and being mean because they are complaining and or asking questions. Our noses are too high in the air for that kind of stuff. It's not like we don't understand why they are complaining. We do.

I once had a patient who greeted every nurse who walked into the room with some of the most foul epitaphs you ever heard. His family was no better. Complained about everything and every nurse everyday with very colourful language. We continued to care for him everyday. That's our job. I don't have time to decide on my personal feelings towards you and even if I do it doesn't matter anyway. If you are sicker than the lovely patient in bed 5 then I deal with you first. You are always going to get the best care I can give considering I have other patients who may be sicker. Lots of people go from lovely to vicious in 0.3 seconds due to disease processes anyway.

On the day this man started to deteriorate we took care of him very well. Well , one nurse that was on duty for him and 13 other patients took care of him very well. She had to neglect much nicer, easier, and more pleasant patients in order to do what she needed to do for grumpy. But he survived.

We get many little old ladies who are worried that the nurses "don't like them" or that they are being a "bad" patient. No chance. You don't need to apologise for throwing up on my shoes, or ringing for the commode when your diuretics start to kick him. If your pain is making you grumpy we understand. If I seem a bit rushed I apologise. It's only because the mean guy in the next bay is sicker and I have to run over to him, but really I'd rather be hanging out with a nice medically stable elderly lady like you. Believe me.

I had one very elderly lady age 98 who would cry and wail whenever she threw up or passed urine "The nurses are going to go mad, they will let me have it!! She didn't have dementia and she lived at home with her son so she wasn't around nurses a lot., otherwise I may have suspected the nursing home. She was just terrified and nothing we said or did reassured the lady. Of course we weren't angry!! We got this a lot with very elderly people. We think that they had stern victorian/edwardian parents and grandparents who beat the crap out them when they were potty training or something. But my god, some of these very elderly people are TERRIFIED of the nurses. It is so heartbreaking. I think a lot of it reflects more on the way things were in their day than the way nurses are now. Images of smallpox hospitals that were like jails for children springs to mind.

Complaining is fine. We understand. Tell us now, not 2 weeks after discharge because you are afraid of repercussions. If you tell us now then maybe we can fix the problem. Sometimes there are things we cannot control. We have no laundry facilities and no place to wash out and hang up soiled garments. It's going to go in a carrier bag in your locker. Sorry. Asking questions about your care, drugs, etc is absolutely fine. If I seem a little rushed it has nothing to do with you and everything to do with what is happening on the ward. I only resent that I can't do more in the way of individualised holistic care.

I don't want anyone to read my blog posts about all the relative rage and think that we label anyone who gets angry, complains, or asks questions as a nutter. Complaining and questioning is one thing. Acting like a raving lunatic every single day while swinging cans of lager at the staff is quite another.

We completely understand where people are coming from with most of the complaints. We also understand that the stress of a hospitalisation will make even the most reasonable people completely lose it. We agree with you that it is completely shit that your mother has not had an immersion bath (only a bed bath instead) for the last few days, and that her soiled nightie is in a carrier bag. Give me a second and I'll run and get you a complaint form and help you write it!!

What do you guys think? Are there many wards where the nurses are dishing out punishment because people are complaining? Whether someone complains or not has never determined how much time I spend with them, the clinical picture for all my patients determines where I go and when. It's been that way every place I have ever worked. God forbid if you were intentionally cruel to a patient because they complained or for any reason.

Are people unaware the fact that their nurse is to busy to give them one to one care and thinking that they are being intentionally neglected? Or are there lots of bully nurses out there? I think this was more of a problem in the past.

10 comments:

"Anne" your posts have certainly opened my eyes to the reality of the pressure you work under although from frequent in patient experience I had guessed as much.

However I find it interesting that even with your even handed approach to patients and relatives who articulate concerns these are almost automatically classified as "complaints" or potential complaints.

I know that this is (far?) too often the case but sometimes concerns are just that. Sometimes potentially helpful suggestions for improvement can be made by reflective observers who happen to be patients or are visiting. At other times people with a negative experience only want it noting and hope that by raising their concerns it will be counted and perhaps acted upon for the benefit of others.

I know that I am talking about a minority and the defensive nature of litigation avoidance almost dictates that every expressed concern is treated as a complaint. Paradoxically this creates a hurdle to patient involvement and as your post indicates real concerns can be unvoiced because of fear of reprisals.

Whether that fear is justified or not is the crux of your question. For me the fact that this fear exists at all speaks volumes for the way the local leadership of the health service has sold out in the last 20 years.

Maybe complaints was the wrong word to use. Most can be classed as concerns.

I think that most concerns do get left unsaid by patients and relatives.

I can't stand the thought of someone being afraid to voice a concern to me because they are afraid that I or we will "get back" at them.

Once I admitted an elderly patient for routine surgery and this person was so terrified I think that if I told him/her to jump he/she would have said how high. It wasn't the surgery that this person was terrified of either, it was staff. I am sure of it. Luckily it was an easy shift and I was able to be there all the time providing reassurance etc.

Maybe that is why so many people completely lose it. They are holding it in, holding it in, and then BOOM.

I think a lot of people in the hospital are intimidated, period. It's busy, it's noisy, they see us working really hard. I know my family gets a little intimidated by the environment. I have never known a nurse to "retaliate" over a complaint or concern. We usually apologize for the complaint and try to make it right or thank them for the concern. I think the media doesn't help things at times. Elderly people see commercials from law firms about nursing home abuse, and I think they draw their own conclusions. There probably are some evil nurses out there who scare people into complicity. Hopefully they are the minority. The nurses on my unit would never mistreat anybody. I think all we can do is make ourselves as approachable as possible and say, "It's okay to tell us if you don't understand something, or ask questions." We would get rid of any nurse who was being mean to patients for any reason. That kind of behavior reflects badly on us all.

I have never experienced a nurse giving purposely bad care to "get back" at someone - I have worked with lazy and indifferent and some just plain stupid nurses in my time - but not so much anyone malicious in that way. Yet even 30 yrs ago in my days as a student nurse I heard some patients saying the same things bout "retaliation" and not wanting "to upset" the nurses etc - so I think its a perception of powerlessness they have - they feel somewhat at our mercy and therefore think of the worst possible scenario?? Without any actual reason for it... And what would be worse than being vulnerable, ill or post op etc in a ward where a nurse was gunning for you? Yikes - scary. So much for our "angels of mercy" label! Also since you are now working under such horrendous pressure I am sure the patients are picking up on your stress - simply from the body language and the expression on your face - the speed with which you are racing about - all these things must say to them - I AM BUSY SO DONT F*CK WITH ME OR ELSE - so they feel insecure and think you are going to blow up if they are "a bother". Sad. I think the Matrons are a huge disappointment - I had such high hopes - when they said they were bringing back Matrons - I thought hooray - the standards of care and staffing etc will go through the roof now because nurses will once again be running their own show! Guess not huh...

One part compost to two or three parts potting soil would be a sufficient combination.When you're preparing your planting area, just mix the soil with about three inches of organic compost. In some cases, the quantity of materials for making compost in the amounts desired (an annual layer 2 inches deep across the garden) cannot be obtained.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.